Abstract

Since historical times, hysteria has colored the literature
from novels to movies. The nomenclature changed from
hysteria to dissociation over time. With More reliable
diagnostic tools being available it became easier to
objectively identify this phenomenon.
However clinical examination still appears to be the sole
diagnostic approach due to ambiguity in results of widely
used investigations like EEG and MRI. Pseudo-seizures
constitute about 25% of total patients of hysteria and 20%
of patients referred to epilepsy centres. There is wide
overlap between two diagnoses. Also possibility of
differential diagnosis needs to be ruled out before labeling
a case with seizures or PNES. Relying long time on
particular diagnosis clinically without undergoing available
investigations can complicate whole scenario. Author
highlights the importance of differential, delayed and dual
diagnosis of Pseudo-seizures and paucity of available
possible tools to diagnose Pseudo-seizures.

Keywords

Seizure; Pseudoseizure; Diagnosis

Introduction

Pseudo-seizures or psychogenic non epileptic seizures
(PNES) are widely known as paroxysmal alterations in
behaviour that resemble epileptic seizures but are without any
organic cause [1]. The incidence of PNES at 1.4 per 100,000
people and 3.4 per 100,000 people between the ages of 15 to
24 years [2]. Author highlights the importance of differential,
delayed and dual diagnosis of Pseudo-seizures and paucity of
available possible tools to diagnose Pseudo-seizures.

Case Report

Fifty year old lady Mrs. G, illiterate, widow from lower socioeconomic
class of rural Southern India presented with
episodes of shaking of both the hands, deviation of mouth to
right side with extension of neck and intense anxiety with
hyperventilation. There were certain episodes of staring at
roof and making tight fists with both the hands. Some of them
featured involuntary movements and speaking difficulty without apparent neurological deficit lasting for 5 minutes
since past 1 year. Patient came with her daughter to our
hospital with anxious affect, preoccupied with multiple
somatic complains and fear of something terrible that may
happen to her. Initial evaluation revealed no focal neurological
deficits and neurologist referred her to psychiatrist for somatic
concerns. Patient was started on Tab. Amitriptyline 10 mg to
25 mg/day.

Following which she had no symptoms of prior episodes for
next 6 months. After 6 months while being on treatment, she
had an episode of chewing movements of mouth with right
unilateral tonic-clonic movements lasting for 30 seconds
followed by confusion which was noticed by her daughter and
patient was admitted in psychiatric ward after two such
episodes.

On examination during 3rd episode in the hospital, patient
was found to be weeping with stiffness of right hand,
extension of neck, deviation of mouth to right side along with
difficulty in breathing and staring at the roof lasting for 5
minutes followed by generalized weakness and numbness of
right cheek. This episode was not associated with jerks, loss of
consciousness, incontinence or fall. Neither affective nor
psychotic symptoms could be elicited. Moreover no definite psychological stress was found. This time physical examination
revealed exaggerated deep tendon reflexes with extensor
plantar on right side.

Patient was observed in the ward for these episodes while Amitriptyline was stopped. EEG study revealed asymmetry
between right and left sides with seizure discharge in right
frontal region. Right fronto-parietal granuloma on CT brain and
multiple areas of susceptibility in right fronto-temporal regions
on MRI Brain explained the nature of symptoms and diagnosis
of frontal lobe seizure was made while starting Carbamazepine
800 mg/day.

After starting Carbamazepine patient was observed in the
ward and had 2 episodes of Head nodding, hand shaking, and
difficulty in speaking which lasted for 30 minutes to 1 hour. On
both the occasions, patient appeared apprehensive, conscious
without neurological deficit. Simultaneously a diagnosis was
revised as frontal lobe seizure with pseudo seizure and she
was started on Tab. Clonazepam 0.5 mg for the apprehension
related to future episodes. Thereafter she continued to follow
up and received Tab. Escitalopram 10 mg for her mixed anxiety depressive symptoms. However no seizure like episode were
reported in subsequent two years of out-patient follow up.

Discussion

Pseudo-seizures are described to have varied
phenomenology including abnormal movements, breathing
difficulty, head nodding and speech arrest with or without
repetition of pattern in subsequent episodes [3]. This does not
make it a stereotyped movement disorder as complex partial
seizures do have semiological similarities with Pseudo-seizures
[4]. In fact frontal lobe seizures are considered to be most
bizarre in their clinical presentation and likely to be missed on
EEGs. Then how does one go about deciding the plan of
management? It is extremely important to have Video EEG
recording of such events; but that again becomes vain efforts
for someone whose episode frequency is very less as
described in our case.

There are no strict distinctions because Pseudo-seizures
have been associated with abnormal brain pathology and ictal
EEG discharges whereas some Frontal lobe seizures are known
to be EEG negative [5]. One thing is sure about these episodes,
that they are invariably associated with certain physiological or
psychological disturbances which can be early life trauma,
interpersonal stressors and chronic stress with abnormal
hormonal response mediating the plastic changes in the brain.
The association is a chance but for a psychiatrist it is extremely
valuable to carry out all possible investigations to benefit the
patient optimally [5]. Missing any of the two diagnosis impacts
the quality of life equally and hence antiepileptic along with
psychotropic can be used whenever necessary with close
follow up.

Certain facets of these dissociative disorders and co-existing
seizure disorder need critical appraisals which has been
discussed under the headings of differential, delayed and dual
nature of diagnosis.

Differential diagnosis

Perhaps the most interesting area in such cases is a
diagnosis of an illness and requires ruling out various other
conditions which are summarized in the Table 1 [6]. Optimum
use of diagnostic procedures should be encouraged in given
clinical setting. Clinical expertise and having a good
therapeutic relationship with the patient has an impact on prognosis. Hence accurate diagnosis matters for a clinician to
have feeling of his expertise as well as for a patient to get
reassured about nature of the condition [7]. This becomes a
key question if specialists want to help their patients rather
than getting out of helpless situation. There are conditions like
encephalitis, syncope, Transient ischaemic attacks which
would bear resemblance to any one of the two disorders
under consideration.

Limbic Encephalitis

Transient ischaemic attacks

Frontal lobe seizures

Autoimmune encephalitis

Complex partial seizures/ Nocturnal epilepsy

Neurodegenerative disorders

Syncope

Tardive dyskinesia

Table 1 Differential diagnosis of PNES.

Detailed serological investigations, EEG recording and
prompt imaging would help clinician to rule out most of these
conditions provided used judiciously when required. Similarly
a diagnosis of dissociative disorders should not be a diagnosis of exclusion but in depth enquiry is expected regarding
patients’ vulnerability to stressors, coping skills, role
modelling, secondary gain and other associated anxiety and
depressive symptoms.

Delayed diagnosis

It is specially mentioned because in most of the cases either
epileptic phenomenon or dissociative phenomenon gets
diagnosed very late in the course of illness. Clearly quality of
life gets worse for these group of patients. Conventionally it
has been seen that a component of psychological distress
often makes a pressure on a psychiatrist to underplay
neurological etiology. On the contrary any organic component
to the illness makes psychiatrist underplay the psychological
aspect of it. Nevertheless this article also highlights the need
for changing traditional role of a psychiatrist and neurologists
to certain extent when it comes to these group of patients [8].
It is always worthwhile to reconsider the diagnostic
possibilities in a case of seizure disorder or PNES if clinical
condition do not improve to a satisfactory level. Considering
diagnostic work up is highly recommended to avoid delayed
diagnosis of any one of these disorders.

Dual diagnosis

Since seizure disorder and PNES can coexist together, it
would also implicate the two different group of therapies for
such cases. The question arrives when it comes to
discontinuation of antiepileptic medications, once psychogenic
cause is conferred. Similarly when diagnosis of seizures is
made, it becomes difficult for a psychiatrist to follow up the
case further but the patient still continue to use psychotropic
medications as and when required. It is a sceptical decision for
neurologist and psychiatrist to play “either or game”. Why it is
not possible to have both the diagnosis over a longitudinal
course of illness? Hence it is possible that patient can have
psychiatric diagnosis earlier and current clinical presentation
reflecting organic pathology or both the diagnosis dating back
few years or presenting with PNES on the background of
chronic seizure disorder [9]. Yes, it needs to be emphasized in
clinical practice and a dual diagnosis if possible should be
given to a patient without compromising the clinical care.

Conclusion

It is a clinical skill to make a healthy balance in diagnosing
seizures and PNES with or without using available investigative
tools. In developing countries where access to specialty care is
challenging, relying on clinical diagnosis plays a key role in determining quality of life of a patient. Since concurrent
diagnosis of seizures and PNES is evidenced by the current
clinical practice, we expect more liaison work between
neurology and psychiatry in future pertaining to these kind of
diagnostic dilemmas. Finally author tries to highlight that we
need to come out of the two dimensional view of diagnosing
either of these disorders and move into three dimensional
concept of Differential, Delayed and Dual nature of seizures-
“3D seizures” in every clinically suspected case.

Acknowledgements

We acknowledge the multidisciplinary team work at our
hospital, NIMHANS.